Provider Demographics
NPI:1114384138
Name:RAU, TENNILLE (NP)
Entity Type:Individual
Prefix:
First Name:TENNILLE
Middle Name:
Last Name:RAU
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 KENDALL DR
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:CO
Mailing Address - Zip Code:81052-3939
Mailing Address - Country:US
Mailing Address - Phone:719-336-0261
Mailing Address - Fax:719-336-0265
Practice Address - Street 1:201 KENDALL DR
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:CO
Practice Address - Zip Code:81052-3939
Practice Address - Country:US
Practice Address - Phone:719-336-0261
Practice Address - Fax:719-336-0265
Is Sole Proprietor?:No
Enumeration Date:2016-01-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0992173363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
0992173OtherLICENSE
CO22730061Medicaid
COMM3777527OtherDEA